Development of a county-based Oklahoma Primary Healthcare Extension System is well underway. We are now proposing to add a Primary Healthcare Improvement Center to support continuous quality improvement in primary care practices with electronic performance feedback, academic detailing, practice facilitation, information technology support, and sharing of best practices. Capacity-building steps will include development of the ability to generate electronic reports for quality improvement and to track improvements in health outcomes and creation of a Navigation and Collaboration Function that connects practices and communities to the research community. The project will accomplish three important tasks: 1) construct an effective and sustainable Primary Healthcare Improvement Center to disseminate and implement the results of patient-centered outcomes research; 2) help 300 small to medium-sized primary care practices improve management of four cardiovascular disease risk factors, smoking, blood pressure, cholesterol, and use of low- dose aspirin; and 3) carefully evaluate the effectiveness of the implementation strategies. The cardiovascular risk reduction project will use a stepped wedge design with randomization of practices by county, stratified by geographic quadrant, to 4 waves of 75 practices, each wave beginning 3-months after the previous wave. A second randomization will assign practices to work first on either smoking cessation and blood pressure control or lipid management and low-dose aspirin switching to the other two after 6 months. The implementation strategies will be continued for a total of one year. Practice performance and patient outcome data will be obtained electronically from the health information exchanges used by the practices at baseline and at 3 month intervals in all practices for 18 months. Practice and intervention characteristics will be measured at baseline, at one year, and at 18 months and their effects on practice performance improvements and patient outcomes will be assessed. We will also measure the impact of the implementation strategies on the components of Solberg's Change Model (priority, change capacity, and care process content) as well as the practice's adaptive reserve. During the third year of the project we will help practices implement processes such as care coordination, HIE-based clinician and patient decision-support, and registry management, processes required for adoption of many future PCOR findings.